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Articles on this Page
- 02/06/11--21:19: _Federal tax id numb...
- 03/07/11--04:47: _Block 28 - 32b on C...
- 03/10/11--00:45: _How to fill box 33 ...
- 04/01/11--04:42: _Using BCBS clear cl...
- 04/03/11--04:42: _Submitting electron...
- 04/06/11--04:43: _Submitting paper cl...
- 04/09/11--04:44: _CMS 1500 OCR - guid...
- 04/11/11--04:48: _what document calle...
- 04/17/11--04:49: _CMS 1500 - Data req...
- 04/20/11--04:52: _UB 04 - Data requir...
- 04/25/11--04:55: _Medicare supplement...
- 04/28/11--04:57: _Additional document...
- 05/01/11--04:59: _CMS 1500 - Helpful...
- 05/03/11--05:01: _UB 04 - claim submi...
- 05/05/11--05:10: _corrected claim - r...
- 07/22/11--05:23: _Basic requirement f...
- 07/27/11--05:33: _In which field and ...
- 08/02/11--05:23: _Completion of UB 04...
- 08/15/11--05:25: _Corrected claim sub...
- 08/30/11--05:27: _Anesthesia claim su...
- 02/06/11--21:19: Federal tax id number and accept assignment field on CMS 1500
- 03/07/11--04:47: Block 28 - 32b on CMS 1500 instruction
- 03/10/11--00:45: How to fill box 33 on CMS 1500
- 04/01/11--04:42: Using BCBS clear claim connection
- 04/03/11--04:42: Submitting electronic claim to BCBS
- 04/06/11--04:43: Submitting paper claim - BCBS
- 04/09/11--04:44: CMS 1500 OCR - guidelines and tips for clean claim
- 04/11/11--04:48: what document called as Medical records
- 04/17/11--04:49: CMS 1500 - Data requirements - quick review
- 04/20/11--04:52: UB 04 - Data requirment - Important field
- 04/25/11--04:55: Medicare supplement claims submission - BCBS
- 04/28/11--04:57: Additional document required to process the claim.
- 05/01/11--04:59: CMS 1500 - Helpful Claims Filing Hints
- 05/03/11--05:01: UB 04 - claim submission hints
- 07/22/11--05:23: Basic requirement for complete claim - CMS 1500
- 08/02/11--05:23: Completion of UB 04 claim - Additional information
- 08/15/11--05:25: Corrected claim submission of CMS 1500 & UB04
Billing instruction for Ambulance Billing - Box 24h to 27
|BlockNo.||Block Name||Block Code||Notes|
|A||Enter the 2-digit visit code, if applicable. Visit codes are especially important if providing services that do not require copay (i.e., for a pregnant recipient or long term care resident.)
For a complete listing and description of
Attachment Type Codes, please refer to the CMS-
1500 Claim Form Desk Reference, located in
Appendix A of the handbook.
Note: When billing for mileage, it is not necessary to enter a visit code, as the Department does not assess a copayment on mileage charges.
|24i||ID Qualifier||A||Enter the two-digit ID Qualifier:
1D = 13-digit Provider ID Number (legacy #)
Provider ID #
|A||Complete with the Rendering Provider's Provider ID number (nine-digit provider number and the applicable four-digit service location – 13-digits total).
Note: Only one rendering provider per claim form.
|24j (b)||NPI||A||Enter the 10-digit NPI number of the rendering provider.|
|25||Federal Tax I.D. Number||M||Enter the provider’s Federal Tax Employer Identification Number (EIN) or SSN and place an X in the appropriate block.
|O||Use of this block is strongly recommended. It can contain up to 10 alpha, numeric, or alphanumeric characters and can be used to enter the patient’s account number or name. Information in this block will appear in the first column of the Detail Page in the RA Statement and will help identify claims if an incorrect recipient number is listed.|
|LB||Do not complete this block.|
Billing instruction for Ambulance Billing - Box 28 to32b
|BlockNo.||Block Name||Block Code||Notes|
|28||Total Charge||LB||Do not complete this block.|
|29||Amount Paid||A||If a patient is to pay a portion of their medical bills as determined by the local County Assistance Office (CAO), enter the amount to be paid by the patient. Patient pay is only applicable if
notification is received from the local CAO on a PA 162RM form. Do not enter copay in this block.
|30||Balance Due||LB||Do not complete this block.|
|31||Signature of Physician or Supplier Including Degree or Credentials||M/M||This block must contain the signature of the provider rendering the service. A signature stamp is acceptable, except for abortions, if the provider authorizes its use and assumes responsibility for the information on the claim. If submitting by computer-generated claims, this block can be left blank; however, a Signature Transmittal Form (MA 307) must be sent with the claim(s).
Enter the date the claim was submitted in this block in an 8-digit (MMDDCCYY) format (e.g.
|32||Service Facility Location Information||LB||Do not complete this block.|
|32a||LB||Do not complete this block.|
|32b||LB||Do not complete this block.|
Billing instruction for Ambulance Billing - Box 33
|BlockNo.||Block Name||Block Code||Notes|
Info & Ph.#
|A/A& M/M||Enter the billing provider’s name, address, and telephone number
Do not use slashes, hyphens, or spaces.
Note: If services are rendered in the patient’s home or facility, enter the service location of the provider’s main office.
|33a||A||Enter the 10-digit NPI number of the billing provider.|
|33b||M/A||Enter the 13-digit Group/Billing Provider ID
number (Legacy #)
Clear Claim Connection
You can simulate the likely procedure code editing rules for your BCBSF claims prior to submission or
after receiving the remittance advice by using Clear Claim Connection; available through the Availity
Health Information Network.
This tool is intended for use as a simulation for general information and is not binding on BCBSF. Medical
Coverage Guidelines, member benefits, terms, limitations and exclusions will override any prepayment
Claims are adjudicated using the claim processing rules for procedure code editing in effect at the time
the claim is submitted. Procedure code edits are typically updated twice per year. Clear Claim Connection
only returns current claim editing logic. Therefore, if your simulation results do not match how your claim
processed, it is possible a version update may be the reason.
Claim editing rules are consistent for most BCBSF claims. Medicare Supplement and Medicare
Advantage Private Fee-for-Service claims are not subject to the procedure code editing rules displayed
by Clear Claim Connection.
How to Use Clear Claim Connection
From Availity’s home page, under the Claims Management Menu tab, click on Research Procedure Code
Edits. Next, you must accept the Terms and Conditions of Use. On the Claim Entry screen, provide the
data listed below and click on the Review Claim Audit Results button. The information returned is
confidential and solely for the use of authorized provider practices.
• Patient’s gender
• Patient’s date of birth
• Procedure code
• Modifiers, if applicable (optional data field)
• Date of service (needed to determine active and non-active procedure codes)
This capability also provides source information and clinical rationale for editing rules, but only on
procedure lines with a “Disallow” or “Review” response in the Recommended data field. To view this
additional information, click on the line to highlight it, then click the Review Clinical Edit Clarification
button. Or, just double click the line to review the related clinical edit clarification.
Note: Use of Clear Claim Connection requires Internet Explorer 5.5 SP1 or higher. For those using a popup
block, this may need to be disabled to view the site.
Electronic Claims Submission
Electronic claims must be filed through the Availity Health Information Network. You may access the
Availity Health Information Network directly or send your claims through a billing service or clearinghouse
to transmit to Availity; Availity will then route to BCBSF. For more information, refer to the Electronic Self-
Service Tools section. For questions about Availity, call (800) AVAILITY (282-4548) or to register, visit
National Provider Identifier
As of May 23, 2008, all health care providers are required to submit a standard unique National Provider
Identifier (NPI) on all electronic transactions. This number replaces all other provider numbers and
identifiers (e.g., UPIN, Medicare, BCBSF number). For additional information on NPI, refer to the CMS
website. Before using your NPI to file claims, you must register it with BCBSF. Simply complete and
return the National Provider Indentifier (NPI) Notification Form, available on our website, www.bcbsfl.com.
Paper Claims Submission
Filing your claims electronically is both quicker and more cost effective. However, there may be times
when it is necessary to file paper claims. The CMS-1500 (or equivalent) and the UB-04 are the claim
forms accepted by BCBSF.
The National Uniform Claim Committee (NUCC) determines the data elements and design of the CMS-
1500. For additional information, including instructions on completing the form, refer to www.nucc.org.
The National Uniform Billing Committee (NUBC) and the Florida State Uniform Billing Committee (SUBC)
determine the data elements and design of the UB-04. These data elements are published in the National
Uniform Billing Data Element Specifications Manual, which contains instructions for completing the UB-04
If you would like to enroll in the UB-04 subscription service to receive a complete UB-04 manual and
updates, visit www.nubc.org. You may also contact the Florida Hospital Association Management
Corporation at www.fha.org or (407) 841-6230.
Optical Character Recognition (OCR)
BCBSF uses OCR scanning equipment to process paper claims. OCR is an automated system that reads
and interprets the characters in each block submitted on the claim form. The information is then sent into
the claims processing system. The more accurately the claim is completed, the less manual intervention
The following guidelines will help in preparing paper claims for OCR scanning:
• Form: Print the claim information in black ink on a blank, red ink CMS-1500 or UB-04 form. You may
also use software programs, which print both the form and the claim information in black ink. Do not
fold, staple or tape your claim.
• Alignment: Align all information within the designated field.
• Font: Use upper case letters in Courier font, size 10 (CMS-1500) or size 12 (UB-04). Do not bold or
• Characters: Do not use special characters (e.g., dollar signs, decimals, dashes, zeros or sevens with
• Names: Omit any titles, such as “Mr.” or “Mrs.” Enter the last name first, followed by a comma, then
the first name.
• Dates: Use an eight-digit format for dates and do not space between numbers (e.g., enter June 15,
2008 as 06152008).
• Time: Use a four-digit format for time, referred to as “units” in block 24G (e.g., enter 1 hour 30
minutes as 0130).
All paper claims go through “front-end” edits that verify eligibility information. Claims that cannot be
scanned by OCR will be returned to the provider with an accompanying explanation. If the claim is
returned, it must be submitted as a new claim; not a “corrected” claim. Returned claims are rejected prior
to processing; therefore, there is not an original claim to correct in the system.
Under certain circumstances, BCBSF will require routine clinical information or medical records for select
procedures/situations. Providers must submit the necessary clinical information with the initial claim.
Failure to submit the needed records may result in processing and payment delays.
Clinical documentation may include, but is not limited to, the following:
• Operative reports
• Physician/nurse notes
• Lab results
• Radiology reports
• Anesthesia notes and time
• Plan of treatment
Claim Filing Addresses
Submit paper claims to the following address (for exceptions, see Dedicated Service Units):
Blue Cross and Blue Shield of Florida
P.O. Box 1798
Jacksonville, FL 32231-0014
Providers must either submit a CMS-1500 (or equivalent) or UB-04 paper claim form with all the
information that is required for original Medicare submission or file the required data electronically. Failure
to complete all required information could result in the claim rejecting, payment delays, and/or additional
development requests. Following are data requirements:
• Patient’s name (block 2)
• Insured’s name (block 4)
• Member ID number (block 1a)
• Patient relationship to member (block 6)
• Patient date of birth (block 3)
• Date of service (block 24A)
• CPT procedure codes with modifiers
when appropriate (block 24D)
• ICD diagnosis code(s) to highest level
of specificity (block 21)
• Place of service (block 24B)
• Unit(s) of service (block 24G)
• Charge(s) (block 24F)
• Performing provider's individual number or professional association (PA) NPI, if applicable (block 24J)
• Federal Tax ID number (block 25)
• Provider of service signature (block 31)
• Billing provider’s information and phone (block 33)
• Billing provider’s NPI, if applicable (block 33a)
• Billing provider’s other ID number (i.e., BCBSF provider number), if applicable (block 33b)
• Provider name (field 1) • Discharge hour (field 16)
• Type of bill (field 4) • Patient status (field 17)
• Federal Tax ID number (field 5) • Revenue code (field 42)
• Statement covers period (field 6) • Payer name (field 50)
• Patient name (field 8) • Health plan ID (field 51)
• Patient address (field 9) • Insured’s name (field 58)
• Patient birth date (field 10) • Patient’s relationship (field 59)
• Patient sex (field 11) • Insured’s unique ID (field 60)
• Admission date (field 12) • Principal diagnosis code and POA indicator (field 67)
• Admission hour (field 13) • Other diagnosis codes (field 67A-Q)
• Type of admission (field 14) • Admitting diagnosis (field 69)
• Source of admission (field 15) • Attending NPI/QUAL/ID/Last/First (field 76)
Medicare Supplement Claims
Medicare Supplement claims should be filed initially to Medicare with BCBSF indicated as the
supplemental carrier. Medicare will usually automatically crossover claims to BCBSF for any applicable
deductible and coinsurance amounts. Claim information will not be crossed over to BCBSF until after
Medicare has processed the claim and released it from the Medicare payment hold.
After receipt of the Medicare Remittance Notice, review the indicators to identify whether the claim was
crossed over directly to BCBSF.
• If the indicator shows the claim crossed over, Medicare has submitted the claim to BCBSF and the
claim is in progress. You do not need to take further action. The 835 (electronic remittance) record
can also carry the secondary forwarding information.
* You will receive payment or processing information from BCBSF after we receive the Medicare
payment. Please allow 45 days from the primary payment date for the processing of the
• If the claim did not crossover automatically, then file the claim to BCBSF with the Medicare
Remittance Notice attached. It is important that you allow 45 days after you receive the Medicare
Remittance Notice before filing the Medicare Supplement insurance coverage claim.
Participating Medicare Select providers have agreed to accept the Medicare allowed amount as paymentin-
full for covered services.
Claim Documentation Requests
When additional documentation is required to process a claim, BCBSF will fax or mail a written request to
you. The request will include a letter and a routing sheet for a specific claim. The letter contains the key
data from the claim (i.e., patient name, member number, patient account number and claim number),
information requested, and the reason additional information is needed. This routing sheet serves as the
fax cover sheet or cover page for documents that are mailed back to BCBSF and is used for tracking
The following are tips for submitting claim documentation when it is requested:
• The Routing Sheet must be only used for the matching documentation. Do not copy the Routing
Sheet for multiple claims; it is for a specific claim and member.
• The Routing Sheet must always be the top sheet attached to the documentation regardless of the
mode of return (i.e., fax, mail).
• When the documentation is returned by fax, the Routing Sheet must be fed from the top of the page
to the bottom of the page.
• Do not attach separate sets together. Fax one information package at a time. Our electronic receiving
system only recognizes the first page as the Routing Sheet and catalogues all subsequent pages
• Do not write on the Routing Sheet except to place an “X” within the applicable boxes to designate
what type of documentation is attached to the Routing Sheet.
• For records that contain greater than 100 pages, mail the documentation to P.O. Box 1798,
Jacksonville, Florida 32231-0014. Package it with the Routing Sheet as the first page.
• Do not send double-sided copies.
• Do not return the original letter that was sent with the Routing Sheet.
Helpful Claims Filing Hints
To prevent claims processing and payment delays, follow the claims filing hints below:
• Verify coverage. Groups often have changes in their health insurance benefit plans. Make reverifying
coverage through the Availity Health Information Network or the telephone self-service
option a routine part of your practice.
• Submit the entire member ID number including alpha prefix. Submit the member ID number not
the member's Social Security number. Remember to correct your billing system when there are
• Complete all claim entry fields. To receive proper reimbursement, the claim information must be
completed in its entirety. Incomplete or inaccurate information will result in a claim denial.
• Enter the date of onset, if applicable. All ICD diagnosis codes in the 800-900 range require a date
of onset (injury, accident, first symptom, etc.).
• Use valid codes. CPT, HCPCS, and ICD codes are updated quarterly. Make sure you or your billing
service is using the most up-to-date codes.
• Report an unlisted code only if unable to find a procedure code that closely relates to or
accurately describes the service performed. Unlisted codes require documentation and therefore
cannot be submitted electronically.
• Use diagnosis codes that indicate a general medical exam when billing for “preventive” health
screening exams. Claims for these services will be denied if other diagnosis codes are used.
• Submit modifiers affecting reimbursement in the first and second position on claims. A
procedure code modifier, when applicable, provides important additional information about the service
• Submit multiple procedures on one claim. All procedures performed on the same date of service,
by the same provider for the same patient should be submitted on one claim.
• Submit all applicable diagnosis codes. Code to the highest level of specificity possible. Most 3-
digit codes require a fourth or fifth digit.
• Include the NPI for rendering physician and billing physician or group. Both the CMS-1500 and
UB-04 include fields for the NPI.
* Block 24J is for Type 1 NPIs (Rendering Physician)
* Block 32a is for Type 2 NPIs (Service Facility)
* Block 33a is for Type 1 or 2 NPIs (Billing Physician/Group)
The above blocks are split to allow your BCBSF provider number in the shaded area and your NPI in
the unshaded area labeled NPI.
* Field 56 is for the NPI of the Billing Facility/Provider
* Field 76 is for Type 1 NPIs (Attending Provider)
* Fields 78 and 79 are for Type 1 NPIs (Other Referring Provider)
• Use the correct Tax ID or Social Security number. For participating providers, the Tax ID number
reported on the claim should match the Tax ID number (TIN) found within the provider agreement,
which is the provider/legal entity's payee TIN. Should your legal entity Tax ID change, please contact
your BCBSF Network Manager directly before claims are submitted containing this new information.
• If services are rendered in other than home or office, enter the complete name and address of
the facility where services were performed. Include the NPI of the facility, if available.
• Submit the correct billing provider information.
* Individual Physicians/Providers: Enter the name, address, phone number, and NPI of the
individual physician, if services were rendered in a solo practice.
* Groups: Enter the name, address, phone number and NPI of the group practice.
• Avoid sending duplicate claims. For claims status, use Availity or call (800) 727-2227. If filing
electronically, be sure to also check your Availity file acknowledgement and EBR for claim level
failures. Allow 15 days for electronic claims and 30 days for paper claims before resubmitting.
• If you do not submit your corrected claims electronically, then indicate “Additional Services”
on claims when billing for additions to the original claim. This will clearly distinguish your claim
as being filed in addition to the original, but not replacing the original claim (i.e., a corrected claim).
The additional services must be submitted on a paper claim form.
A corrected claim is a claim that has already been processed, whether paid or denied, and is resubmitted
with additional charges, different procedure or diagnosis codes or any information that would change the
way the claim originally processed.
Claims returned requesting additional information or documentation should not be submitted as corrected
claims. While these claims have been processed, additional information is needed to finalize payment.
Note: BCBSF does not consider a corrected claim to be an appeal.
When submitting a paper corrected claim, follow these steps:
• Submit a copy of the remittance advice with the correction clearly noted.
• If necessary, attach requested documentation (e.g., nurses notes, pathology report), along with the
copy of the remittance advice. To ensure documents are readable, do not send colored paper or
• Boldly and clearly mark the claim as “Corrected Claim” and attach the completed Provider Claim
Inquiry Form (available at www.bcbsfl.com). Failure to mark your claim appropriately may result in
rejection as a duplicate.
• If a modifier 25 or 59 is being appended to a CPT code that was on the original claim, do not submit
as a “Corrected Claim” instead, submit as a coding and payment rule appeal with the completed
Provider Appeal Form (available at www.bcbsfl.com) and supporting medical documentation (e.g.,
operative report, physician orders, history and physical)
When submitting an electronic corrected claim through the Availity Health Information Network, use the
Bill and Frequency Type codes listed below.
• 7 – Replacement of Prior Claim
If you have omitted charges or changed claim information (diagnosis codes, dates of service, member
information, etc.), resubmit the entire claim, including all previous information and any corrected or
additional information. Hospitals and facilities should include the seven in the third digit of the Bill
Type. Physicians should submit with a Frequency Type code of seven.
• 8 – Void/Cancel of Prior Claim
If you have submitted a claim to BCBSF in error, resubmit the entire claim. Hospitals and facilities
should include the eight in the third digit of the Bill Type. Providers should submit with a Frequency
Type code of eight. If the claim was paid, resubmit the claim to BCBSF via paper and attach a check
for the amount that was paid in error.
Complete claims requirements
• Member’s name
• Member’s address
• Member’s gender
• Member’s date of birth (dd/mm/yyyy)
• Member’s relationship to subscriber
• Subscriber’s name (enter exactly as it appears on the member’s health care ID card)
• Subscriber’s ID number
• Subscriber’s employer group name
• Subscriber’s employer group number
• Rendering Physician, Health Care Professional, or Facility Name
• Rendering Physician, Health Care Professional, or Facility Representative’s Signature
• Address where service was rendered
• Physician, Health Care Professional, or Facility “remit to” address
• Phone number of Physician, Health Care Professional, or Facility performing the service (provide this information
in a manner consistent with how that information is presented in your agreement with us)
• Physician’s, Health Care Professional’s, or Facility’s National Provider Identifier (NPI) and federal Tax Identification
• Referring physician’s name and TIN (if applicable)
• Date of service(s)
• Place of service(s) (for more information see: cms.hhs.gov/PlaceofServiceCodes/Downloads/placeofservice.pdf)
• Number of services (day/units) rendered
• Current CPT-4 and HCPCS procedure codes, with modifiers where appropriate
• Current ICD -9-CM (or its successor) diagnostic codes by specific service code to the highest level of specificity (it is essential to communicate the primary diagnosis for the service performed, especially if more than one diagnosis is related to a line item)
• Charges per service and total charges
• Detailed information about other insurance coverage
• Information regarding job-related, auto or accident information, if available
• Retail purchase cost or a cumulative retail rental cost for DME greater than $1,000
• Current NDC (National Drug Code) 11-digit number for all claims submitted with drug codes. The NDC number must be entered in the 24D field of the CMS-1500 Form or the LIN03 segment of the HIPAA 837 Professional electronic form.
How to submit NPI, TIN and taxonomy on a claim
The information below provides the location for NPI, TIN and Taxonomy on paper and electronic claims. See definitions in the UB-04 Data Specifications Manual.
HIPAA 837P (Professional) Claim Transaction
Primary identifier loop 2010aa, NM109
Pay-To Provider Federal Tax id loop 2010aB, NM109
Referring Physician loop 2310a, NM109
Rendering Physician loop 2420a, NM109
HIPAA 837I (Institutional) Claim Transaction
Billing Provider Primary id loop 2010aa, NM109
Billing Provider Taxonomy loop 2000a, PRV03
Billing Provider Secondary id (EiN) loop 2010aa, REF02
attending Physician loop 2310a, NM109
Operating Physician loop 2310B, NM109
HICF 1500 (08-05) Professional Claim Form
Referring Provider NPi Field 17b
Rendering Provider NPi Field 24j
Service Facility location NPi Field 32a
Billing Provider NPi Field 33a
Billing Provider legacy identifier Field 33b
important: Make sure that your claim software supports the revised 1500 claim form (08-05) Reference the 1500
Reference instruction Manual at nucc org for specific details on completing this form
UB-04 Paper Institutional Claim Form
Billing Provider NPi locator 56
Billing Provider Taxonomy code locator 81
attending Provider NPi locator 76
Operating Provider NPi locator 77
Other Provider NPi locator 78-79
Additional information needed for a complete UB-04 form
• Date and hour of admission
• Discharge date and hour of discharge
• Member status-at-discharge code
• Type of bill code (three digits)
• Type of admission (e.g. emergency, urgent, elective, newborn)
• Current four-digit revenue code(s)
• Current principal diagnosis code (highest level of specificity) with the applicable Present on Admission (POA) indicator on hospital inpatient claims per CMS guidelines
• Current other diagnosis codes, if applicable (highest level of specificity), with the applicable Present on Admission (POA) indicator on hospital inpatient claims per CMS guidelines
• Current ICD -9-CM (or its successor) procedure codes for inpatient procedures
• Attending physician ID
• Bill all outpatient procedures with the appropriate revenue and CPT or HCPCS codes
• Provide specific CPT or HCPCS codes and appropriate revenue code(s) (e.g., laboratory, radiology, diagnostic or therapeutic) for outpatient services
• Complete box 45 for physical, occupational or speech therapy services (revenue codes 0420-0449) submitted on a UB-04
• Submit claims according to any special billing instructions that may be indicated in your agreement with us
• On an inpatient hospital bill type of 11x, the admission date and time should always reflect the actual time the
member was admitted to inpatient status
• If charges are rolled to the first surgery revenue code line on hospital outpatient surgery claims, a nominal monetary amount ($.01 or $1.00) must be reported on all other surgical revenue code lines to assure appropriate adjudication
If you need to correct and re-submit a claim, submit a new CMS-1500 or UB-04 indicating the correction being made.
When correcting or submitting late charges on a CMS-1500, UB-04 or 837 Institutional claim, resubmit all original lines and charges as well as the corrected or additional information. When correcting UB-04 or 837 Institutional claims, use bill type xx7, Replacement of Prior Claim. Do not submit corrected or additional charges using bill type xx5, Late Charge Claim. Hand-corrected claim re-submissions will not be accepted.
Electronic Claim Submission
(EDI Support Line)
To obtain information on HIPAA Transactions & Code sets go to hipaa.uhc.com Uniprise
Companion Document Additional United Healthcare and Affiliates’ payer ID s
can be found on UnitedHealthcare Online.com
Claims & Payments Electronic Claims
Submissions, under EDI Tools & Resources
Reporting requirements for anesthesia services
• One of the CMS-required modifiers (AA, AD, QK, QX, QY, QZ, G8, G9 or QS) must be used for anesthesia services reporting.
• For electronic claims, report the actual number of anesthesia minutes in loop 2400 SV104 with an “MJ” qualifier in loop 2400 SV103. For CMS-1500 paper claims, report the actual number of minutes in Box 24G with qualifier MJ in Box 24H.
• When medically directing residents for anesthesia services, the modifier GC must be reported in conjunction with the AA or QK modifier.
• When reporting obstetrical anesthesia services, use add-on codes 01968 or 01969, as applicable, on the same claim as the primary procedure 01967.
• When using qualifying circumstance codes 99100, 99116, 99135 and/or 99140, report the qualifier on the same claim with the anesthesia service.